Allegany Health Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Maryland.
- Location
- 730 Furnace Street, Cumberland, Maryland 21502
- CMS Provider Number
- 215230
- Inspections on file
- 17
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Allegany Health Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to hold and document an interdisciplinary care plan meeting after completion of an MDS assessment for a resident with a urinary catheter. The social worker reported that care conferences are usually scheduled about 2 weeks after MDS assessments and documented in the EHR. Record review showed an MDS completed for the resident, but the only documented care conference was several months earlier, with no subsequent meeting held. The social worker and NHA confirmed that no care plan meeting had occurred since that earlier date, attributing this to the resident’s transition from LTC to skilled care.
A resident was readmitted from the hospital with an indwelling Foley catheter placed for urinary retention, with instructions for outpatient urology follow-up. The facility documented ongoing catheter orders and noted the device on the MDS, but failed for several months to include the catheter in the resident’s care plan or to develop interventions related to its use. No timely urology appointment was arranged, and there was no documentation of any attempt to discontinue the catheter, even after the resident developed hematuria and was treated for cystitis. The facility also lacked a facility-specific policy addressing catheter use and plans for discontinuation.
A resident was admitted without a clear physician's order for end-of-life care, and facility staff failed to initiate CPR when the resident was found not breathing. Despite prior education on CPR and MOLST forms, an LPN and RN supervisor did not act due to the absence of a completed MOLST form, leading them to wait for EMS. The facility's policy required staff to treat residents as full code in emergencies without a completed MOLST form.
Two residents suffered injuries due to staff failing to follow care plans in a LTC facility. One resident fell out of bed during incontinence care, resulting in bilateral femoral neck fractures, as the GNA did not use the required two-person assist. Another resident sustained a fractured humerus during a manual transfer to a shower chair, contrary to the care plan requiring a lifting device. Staff did not verify care plans before performing tasks, leading to improper handling and supervision.
A resident was subjected to abuse when a staff member, GNA2, kicked them on the leg, causing a skin tear, after the resident attempted to remove food trays. The incident was witnessed by an LPN who reported it to a supervisor. GNA2 was verbally aggressive and attempted to move the resident backward before the physical altercation occurred.
The facility failed to implement its abuse policy when two staff members reported an allegation of sexual abuse between two residents. An anonymous complaint indicated that the administration required a nurse to retract documentation of the incident, and the facility did not report the abuse to the State Survey Agency. Despite the facility's policy requiring immediate reporting and investigation, no formal documentation or notification to authorities occurred.
A facility failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. The incident involved two residents, with one observed touching the other's genitals. Despite being reported to the Director of Social Work and the facility Administrator, no proper documentation or investigation was conducted, and the incident was not reported to authorities as required by facility policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff. The incident involved two residents, with one observed touching the other's genitals. Despite being informed, the facility's leadership did not document or investigate the incident, nor did they notify the local police or State Survey Agency, contrary to their policy.
A resident was improperly restrained in a geriatric chair and wheelchair with a lap tray, preventing her from standing up, which was done for staff convenience. The facility's policy requires restraints to be used only as a last resort with proper documentation, which was not followed. The resident, who was cognitively intact, expressed anxiety due to the inability to move freely, and staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints.
A facility failed to update a resident's care plan to include the use of a geriatric chair and lap trays, which were used as restraints. The resident, cognitively intact, was placed in these devices after a fall, but the care plan did not reflect this. Staff confirmed the oversight, and the DON and Administrator did not recognize these as restraints, leading to potential safety risks.
Failure to Hold Interdisciplinary Care Plan Meeting After MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an interdisciplinary care plan meeting was held to review and revise a resident’s care plan following completion of a Minimum Data Set (MDS) assessment. Care conferences, also known as care plan meetings, are required interdisciplinary team meetings that are to occur after MDS assessments, which provide the information needed to develop and modify the resident’s care plan. Interview with the social worker revealed that MDS nurses send out a schedule and social work typically schedules care plan meetings 14 days after the assessment date, with documentation of these meetings maintained in the electronic health record. Medical record review for a resident with a urinary catheter showed an MDS with an assessment reference date of 1/9/26. Further review of the record revealed documentation of a care conference on 10/15/25, but no documentation of any care conference occurring after the 1/9/26 MDS assessment. When questioned, the social worker and the Nursing Home Administrator confirmed that no care plan meeting had been held since October, and the NHA stated this was due to the resident transitioning from long-term care to skilled care. This failure to hold and document an interdisciplinary care plan meeting after the MDS assessment constituted the cited deficiency.
Failure to Care Plan and Reassess Indwelling Foley Catheter Use
Penalty
Summary
Surveyors identified a failure to develop and implement a care plan addressing an indwelling urinary catheter and to assess for its possible removal for a resident who had been readmitted from the hospital with a Foley catheter in place. The resident had previously resided in the facility for more than a year and, prior to a hospital stay in late December, was documented on the discharge MDS as frequently incontinent of urine without any internal or external catheter. During the hospitalization, the resident developed urinary retention and urology placed a Foley catheter with the plan for it to remain in place at discharge and for the resident to follow up with urology as an outpatient. Upon the resident’s readmission in early January, facility records showed ongoing orders for an indwelling Foley catheter and catheter care every shift, and the MDS assessment dated shortly after readmission documented the presence of an indwelling urinary catheter. However, review of the care plan on April 1 revealed no documentation acknowledging the catheter or interventions related to its use, despite the catheter having been in place since January. The existing care plan only addressed occasional bladder and bowel incontinence and, even when it was reviewed and revised in March by an RN, it still did not address the indwelling catheter or the resident’s recent urinary issues. Further record review showed no orders for a urology appointment and no documentation that the resident had been seen by urology or that any attempt had been made to discontinue the catheter after readmission. Progress notes from primary care providers in early January referenced the difficult Foley placement and the need for outpatient urology follow-up, but this follow-up was not arranged at that time. In March, the resident developed hematuria and was treated for cystitis with hematuria, yet the care plan remained unchanged and still did not address the catheter or the recent urinary tract infection. The facility also lacked a facility-specific policy on catheter use and discontinuation, relying instead on a textbook reference that noted complications associated with indwelling catheter use.
Failure to Initiate CPR Due to Incomplete MOLST Form
Penalty
Summary
The facility staff failed to identify a newly admitted resident who was admitted without a clear physician's order for end-of-life care and did not follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This deficiency was evident for one resident during an annual recertification survey. The resident was admitted from the community and had been evaluated in the emergency room earlier in the day. Upon admission, the resident was assessed by a physician and deemed incapable of understanding any information, necessitating a third party to make decisions on their behalf. During the night, the resident was found on a floor mat by the bed but showed no evidence of injury and was placed back in bed. Later, a staff member noticed changes in the resident's breathing pattern and alerted an LPN, who assessed the resident and found them not breathing with eyes rolled back. The LPN notified 911/EMS and applied oxygen but did not initiate CPR. The LPN and an RN supervisor reviewed the resident's medical record and could not find a completed MOLST form, leading them to wait for emergency services to arrive. CPR was not performed, and the resident was pronounced deceased by EMS upon arrival. Interviews with staff revealed that the LPN had received prior education on CPR and MOLST forms but did not act due to the absence of a completed MOLST form. The former Social Work Director stated that newly admitted residents without a completed MOLST form should be considered full code in emergencies. However, there was no documentation of advance directives or MOLST status in the resident's progress notes. The facility's policy indicated that in the absence of appropriate DNR identification or orders, staff should respond with CPR measures and treat the resident as a full code.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility staff failed to provide adequate supervision and follow the resident's plan of care, resulting in harm to two residents. In the first incident, a resident with cognitive impairment and total dependence on staff for care fell out of bed during incontinence care, leading to bilateral femoral neck fractures. The GNA responsible for the resident's care did not adhere to the care plan, which required two staff members for bed mobility. The GNA turned the resident onto their side and left them unattended while seeking additional supplies, resulting in the resident rolling out of bed. In the second incident, another resident with a history of a fractured hip, dementia, and metabolic encephalopathy suffered a fractured humerus during a transfer to a shower chair. Two GNAs attempted to transfer the resident manually, contrary to the care plan that required the use of a lifting device. During the transfer, they heard a popping sound and lowered the resident to the floor. The GNAs had not reviewed the resident's updated care plan, which specified the use of a Hoyer lift for transfers. Both incidents highlight a failure to adhere to established care plans and protocols, resulting in significant injuries to the residents. The staff involved did not verify the residents' care plans before performing tasks, leading to improper handling and supervision. These deficiencies were identified during a survey, and the facility was found to have past noncompliance with a compliance date established after corrective measures were implemented.
Resident Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure that a resident remained free of abuse, as evidenced by an incident involving a staff member, GNA2, who was witnessed kicking a resident on the right lower leg. This incident occurred when the resident attempted to remove food and meal trays from a food cart. GNA2, who was verbally aggressive, attempted to move the resident backward by holding the wheelchair handles and subsequently kicked the resident, resulting in a skin tear. The resident expressed distress by screaming and wheeling themselves down the hall, where they were later found crying by another staff member, LPN5, who observed the injury and reported the incident to a supervisor. The incident was substantiated through witness statements, including that of LPN5, who detailed the sequence of events leading to the abuse. The resident was initially told by GNA2 to return to their room after being informed they had already eaten. Despite the resident's request to be left alone, GNA2 persisted in trying to move the resident, leading to the physical altercation. The facility's investigation confirmed the abuse, and GNA2 was immediately suspended and subsequently terminated following the incident.
Failure to Implement Abuse Policy and Procedures
Penalty
Summary
The facility failed to implement its existing abuse policy and procedures when an allegation of sexual abuse was reported by two staff members. An anonymous complaint revealed that a resident was observed sexually assaulting another resident, and the facility administration allegedly required a licensed nurse to retract their documentation of the incident. Furthermore, the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. Interviews with the Director of Social Work and the facility Administrator confirmed that an investigation was initiated, but there were no administrative documents or investigative records regarding the alleged abuse. Additionally, the local police and the State Survey Agency were not notified. The facility's leadership did not adhere to its policy, which mandates immediate reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy requires reporting to the State Survey Agency within two hours of receiving an allegation and conducting a prompt investigation. However, the facility failed to document the incident properly, did not collect witness statements, and did not notify the appropriate authorities. The staff were aware of the resident's history of intrusive behaviors, yet no formal investigation or documentation was completed, leading to a deficiency in handling the reported abuse incident.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility administrative staff failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The incident was initially reported by a GNA to the Director of Social Work, who then informed the facility Administrator and the Director of Nurses. However, the facility did not document or investigate the incident properly, and no report was made to the State Survey Agency or local police. The facility's policy requires immediate reporting of such allegations, but this was not adhered to. The nurse who documented the incident in the alleged perpetrator's medical record found that the progress note was later marked as invalid, and no formal witness statements were collected. The facility Administrator admitted that there were no administrative documents or investigative records regarding the alleged abuse, and the staff were aware of the resident's intrusive behaviors but failed to take appropriate action.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility administrative staff failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff members. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The Director of Social Work was informed of the incident and reported it to the facility Administrator and the Director of Nurses. However, there were no administrative documents or investigative records regarding the alleged abuse, and the local police and State Survey Agency were not notified. The facility's policy requires immediate reporting and investigation of any allegations of abuse, but this was not followed. A staff nurse documented the incident in the alleged perpetrator's medical record, but the progress note was later marked as invalid without explanation. The nurse who reported the incident was not asked to provide a formal witness statement or interviewed by administrative staff. The facility's leadership failed to conduct a prompt investigation or implement immediate actions to safeguard the residents involved.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed with one resident who was placed in a geriatric chair and a wheelchair with a lap tray. These devices prevented the resident from standing up, which was done for staff convenience rather than medical necessity. The facility's policy clearly states that restraints should only be used as a last resort and must be documented with a physician's order reflecting a qualifying medical symptom, which was not done in this case. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was observed multiple times in a geriatric chair and a wheelchair with a lap tray, unable to stand or move freely. The resident's care plan did not include any interventions or assessments for the use of these restrictive devices. Staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints, and the resident expressed feelings of anxiety and nervousness due to the inability to move freely. Interviews with the Director of Nursing (DON) and the Administrator indicated that they did not consider the geriatric chair with an overbed table or the wheelchair with a lap tray as restraints, and no assessments or care planning were completed to ensure the resident's safety. The resident was often placed in these devices without attempts to allow her to sleep in her bed, further indicating the use of these devices for staff convenience rather than the resident's best interest.
Failure to Revise Care Plan for Restraint Use
Penalty
Summary
The facility failed to revise the care plan for a resident to include the use of a geriatric chair and lap trays, which were considered restraints. The resident, who was cognitively intact with a BIMS score of 14 out of 15, was admitted to the facility and later placed in a geriatric chair after a fall. However, the care plan did not reflect the use of these devices, which were intended to prevent falls. Observations revealed the resident was often placed in a geriatric chair or a wheelchair with a lap tray, and staff intervened to keep the resident seated, indicating the devices were used as restraints. Interviews with nursing staff, including LPNs and RNs, confirmed that the care plan had not been updated to include the use of these restrictive devices. The MDS nurses were unaware of the resident's placement in a geriatric chair and the use of a lap tray, and the Director of Nursing and Administrator did not consider these devices as restraints. This oversight placed the resident at risk for unmet care needs and safety risks, as there was no assessment or care planning to ensure the resident's safety with these devices.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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